The MVH Care Coordinator supports MVH's initiatives toward clinical integration and accountable care strategies to achieve the triple aim in healthcare: 1) improving quality and patient satisfaction, 2) improving outcomes and the overall health of the population, and 3) reducing the total cost of care. Through risk stratification tools available to MVH, the MVH Care Coordinator identifies patients with a need for early intervention related to discharge education, transitional care or disease management and coordinates intervention with PCPs and other care providers. The MVH Care Coordinator also refers to medical and behavioral health providers as appropriate for further intervention.
- Assists in setting appropriate care plan and/or discharge goals in collaboration with patient, family and physician as well as available community resources.
- Collaborates with members of the inpatient and outpatient healthcare team to ensure that care plan/discharge goals are met and aligned with readmission reduction activities planned.
- Collaborates with MVH quality staff and Medical Director to define goals, develop effective protocols and implement an effective population health management program.
- Identifies patients at high risk for readmission or over-utilization based on population data and helps to coordinate appropriate intervention with care providers.
- Fosters collegial relationships with MVH and other community providers across the entire continuum of care to help ensure optimal care coordination and in-network referral management.
- Interprets data on patients at high risk for readmission or unnecessary utilization and communicates timely to the appropriate resources.
- Licensed Practical Nurse or Registered Nurse
- Must have current license in the State of Idaho.
- To function effectively in this role, it is preferred that candidate have experience in both inpatient and outpatient care settings. Health plan experience is a plus.
- Past experience with Care/Case Management, Population Health Management, Utilization Review/Management is highly preferred.
- Care/Case Management or Population Health Management Certification (or ability to obtain certification within three years after hire) is required.
Knowledge, Skills and Abilities:
- Solid understanding of the healthcare continuum
- Demonstrate sound judgment, patience and maintain a professional demeanor at all times
- Ability to work in a busy and stressful environment
- Organizational skills and the ability to prioritize
- Computer skills: Word, Excel, Outlook, Electronic medical records software
- Strong interpersonal verbal and written communication skills
- Ability to utilize data and reports to develop actionable interventions and measurable goals
- Creativity, complex problem analysis and decision making
- Ability to work varied shifts
Job Type: Full-time
- One location
- Multiple locations